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05.00.31e, Pulse Oximetry Devices in the Home Setting
Independence Blue Cross·PA · Pulmonology, Cardiology, Pediatrics +2 more·Medical Policy
We identified it
Jun 19, 2026
Summary
Independence Blue Cross reissued Policy 05.00.31e on 03/18/2026 with no substantive changes to pulse oximetry coverage criteria. The policy continues to cover home pulse oximetry devices only for patients on oxygen therapy or being evaluated for oxygen with specific medical indications (chronic respiratory/cardiovascular/neuromuscular disease, active weaning, tracheostomy/mechanical ventilation, or pediatric conditions). All other uses remain not covered. Billing teams should verify that claims align with the existing medical necessity criteria and required documentation standards.
Action Required
No immediate action required. This is a reissue with no changes to coverage criteria, billing codes, or documentation requirements. Billing team should confirm current claim submission processes continue to align with existing policy criteria: (1) verify patient has qualifying diagnosis (chronic respiratory/cardiovascular/neuromuscular disease, active oxygen weaning, tracheostomy, mechanical ventilation, or pediatric condition), (2) confirm prescriber documentation includes capacity assessment for oxygen adjustment, and (3) maintain standard written order on file before billing E0445 or A4606. Continue applying existing prior authorization practices if currently in place. No workflow or system updates needed.